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Evoke Wellness and Health Coaching Forms Packet Wellness and Health Coach: Sandra Labella, PT, CWHC Date

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Evoke Wellness and Health Coaching Forms Packet Wellness and Health Coach: Sandra Labella, PT, CWHC Date Evoke Wellness and Health Coaching Forms Packet Sandra LaBella, PT, CWHC Date: Wellness and Health Coach: Laying the Foundation for Coaching As your coach, it’s important for me to understand how you view the world, yourself, and your job or career. Each person is unique and understanding you will help me support and assist you. Answering these questions clearly and thoughtfully, will serve both you and me. You may find that they help you clarify perceptions about yourself and the direction of your life. These are “pondering” type questions, designed to stimulate your thinking in a way that will make our work together more productive. Take your time answering them. If they are not complete by our first (foundation) session, just bring what you have completed and finish the rest later. These answers will be treated with complete professional confidentiality. What do want to get from the coaching relationship? What is the “best” way for me to coach you most effectively, what tips would you give to me about what would work best? Do you have any apprehension or pre-conceived ideas about coaching? 1 Evoke Physical Therapy and Wellness Center, LLC What are 3 things you would like to me to know about you? 1. 2. 3. Personal 1. What accomplishments or events must, in your opinion, occur during your lifetime to consider your life satisfying and well lived? 2. What is (or might there be) a secret passion in your life? Something you may or may not have allowed yourself to do so far, but which you would really love to do. 3. What unique gift or knowledge do you have to contribute? 4. Please describe what gives you a sense of purpose in life? What activities have meaning for you? 5. What’s missing in your life, the presence of which would make your life be more fulfilling? 2 Evoke Physical Therapy and Wellness Center, LLC 6. What do you do when you are really up against the wall? Health & Wellness Information As your coach, my job is not to “treat” you, but to be your ally and your resource. When it comes to health and wellness issues I will help you discover steps you may choose to take towards greater health and higher levels of wellness. As your ally, I may refer you to medical, psychological, nutritional and other health-related services for more information and to seek any treatment in these areas. I can be a source of support and accountability, helping you to follow through with any treatment plans that you devise with these other professionals. Please share with me information about your health and wellness so that I may more fully understand your health challenges and aspirations for higher levels of wellness. 1. Please describe your lifestyle and what you do to be healthy and well. 2. Please describe any health challenges that you currently experience (major concerns as well as just bothersome things like headaches, insomnia, etc.) 3. Are you currently on any medications? If so what is the name of the medication and the intended impact of the medication? 4. What do you do to reduce stress in your life, or to counter-act the effect of stress in your life? 3 Evoke Physical Therapy and Wellness Center, LLC 5. Please describe a typical week in terms of diet and exercise/activity. 6. What do you do in your life that brings you happiness and joy? How often do you do this? 7. What gets in the way of you doing what brings you joy and health in the world? 8. How can a coach be of assistance in helping you make the lifestyle changes you’d like to make? 9. What two steps could you take immediately that would make the greatest difference in your current situation? 4 Evoke Physical Therapy and Wellness Center, LLC GENERAL INTAKE FORM I. General Information Section: First Name _________________________ Last Name _________________________ Middle Initial ___ Address __________________________________________________________________________________________ DOB _____/_____/_____ Age _____ ⃝ Married ⃝ Single ⃝ Divorced Occupation ________________________________________________________________________________________ Email ____________________________________________ Home Phone ____________________________________ Cell Phone ________________________________ Work Phone _____________________________________________ Emergency Contact ________________________________ Phone __________________________________________ Family Doctor _______________________________ Phone _________________________________________________ Address ____________________________________________ Insurance _____________________________________ Who May We Thank For Referring You? _________________________________________________________________ II. Goal Section: ⃝ I am seeking wellness services for one of the following: Reiki, Health Coaching and or Craniosacral. ⃝ My Goals are ____________________________________________________________________________________ Please Note: Reiki does not take the place of medical care. It is recommended that you see a licensed physician or health care professional for any pain, physical or psychological aliment you may have. III. Current Medical History ⃝ Do You Have Any Current Concerns Or Complaints? ⃝ Yes ⃝ No If yes, please describe: ________________________ __________________________________________________________________________________________________ Do You Have Any Pain? Are You Under The Care Of A Physician For Any Medical Condition? ⃝ Yes ⃝ No If Yes, Please Describe: __________________________________________________________________________________________________ Are You Receiving Any Other Services Or Treatments? ⃝ Yes ⃝ No If Yes, Please Describe: _______________________ __________________________________________________________________________________________________ IV. Medications /Vitamins/Dietary Supplements: _________________________________________________________ __________________________________________________________________________________________________ V. Allergies: _______________________________________________________________________________________ VI. Past Surgical History: Please List and Date All Surgeries __________________________________________________ __________________________________________________________________________________________________ VII. Recent Medical Complaints: Please Check All That Apply To You ⃝ Black Tarry Stools ⃝ Chest Pain ⃝ Coughing Up Blood ⃝ Unexplained Weight Loss ⃝ Blood in Stool ⃝ Excessive Fatigue ⃝ Blurred Vision ⃝ Night Sweats ⃝ Blood in Urine ⃝ Shortness of Breath ⃝ Continuous Diarrhea ⃝ Doctor Notified ⃝ Yes ⃝ No 5 Evoke Physical Therapy and Wellness Center, LLC GENERAL INTAKE FORM VIII. Past Medical History: Please Check All That Apply To You ⃝ High/Low Blood Pressure ⃝ Chronic Fatigue ⃝ Constipation ⃝ Heart Conditions ⃝ Fibromyalgia ⃝ Irritable Bowel Syndrome ⃝ Pacemaker ⃝ Multiple Sclerosis ⃝ Incontinence ⃝ Diabetes ⃝ Depression ⃝ Bladder Problems ⃝ High Cholesterol ⃝ Anxiety ⃝ Bowel Problems ⃝ Cancer ⃝ Osteoporosis ⃝ Kidney Disease ⃝ Chemotherapy/Radiation ⃝ Prostate Problems ⃝ Sexual/Physical Abuse ⃝ Anemia ⃝ Back Pain ⃝ Sexually Transmitted Disease ⃝ Bleeding Disorder ⃝ Numbness/Tingling ⃝ Liver Disease ⃝ Blood Clot/Embolism ⃝ Pelvic Pain ⃝ Hepatitis ⃝ Cerebral Hemorrhage/Stroke ⃝ TMJ Pain ⃝ Alcoholism | Drug Problem ⃝ Head Injury/Recent Skull Fracture ⃝ Sports Injuries ⃝ Smoking History ⃝ Acute Aneurysm ⃝ Arthritis ⃝ Vison Loss | Problems ⃝ Headaches ⃝ Joint Replacement ⃝ Life Threatening Allergies ⃝ Seizures/Epilepsy/Convulsions ⃝ Pins or Metal Implants ⃝ Latex Allergy ⃝ Asthma ⃝ Fractures ⃝ Allergy: Coconut |Beeswax |Perfume ⃝ Emphysema ⃝ Hypothyroid/Hyperthyroid ⃝ Trouble Sleeping ⃝ Acid Reflux/Belching ⃝ Hyperglycemia/Hypoglycemia ⃝ Hearing Loss ⃝ Anorexia/Bulimia ⃝ Dizziness/Fainting ⃝ Currently Pregnant ⃝ Other _________________ ⃝ Other _______________ ⃝ Other __________________ IX. Acknowledgement of Receipt of Notice of Privacy Practices: SIGNATURE: I, ____________________________________________________, acknowledge that I have received the Notice Of Privacy Practices for Evoke Physical Therapy and Wellness Center, Inc. I have had full opportunity to read or have had read to me and consider the contents. I Consent to use and disclosure of your Notice of Privacy Practices. X. Privacy Authorization: Your Rights: When it comes to your protected health information you have the right to request confidential communications or that communication be made by alternative means. You may contact: ⃝ Cell ⃝ Home ⃝ Work. Leave Message ⃝ With Family ⃝ Voice Mail ⃝ Text ⃝ Email We are happy to include you in our Email Newsletter, Special Events & Educational Lectures. Please let us know if you do not wish to subscribe. ⃝ Yes Include Me ⃝ No, I Do Not Wish To Subscribe Email and Text Messaging is a NON-SECURE Network and Confidentiality Cannot be Guaranteed. XI. Electronic Payment Communications: We accept cash, check or credit. It is your right to pay for fees electronically, using a credit or debit card. The financial services company we use is Square. For more info see: www.squareup.com. In order to utilize Square and maintain HIPPA Regulations, we must limit our activities to only normal financial transaction services. What this means is we cannot offer you the automatic receipt or text receipt services that are normally offered by square. We have turned this automatic function off and can provide you with a receipt. Although we provide reasonable means to protect your privacy, please consider the associated risks of electronic payment communications. ⃝ I wish
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